Journal Club: Nathan Gause Mytendinous Rupture of the PTT with Associated Fibular Fracture
June 2025
JRGOS Journal Club
Myotendinous Rupture of the Posterior Tibial Tendon with Associated Fibular Fracture: A Case Report
Zachary Podoll, MD, Parker Boyce, BS, Nathan Gause, MD, and Jonathan Dubin, MD
JBJS Case Connect. 2025 May 22;15(2). doi: 10.2106/JBJS.CC.24.00578. PMID: 40403119.
L. Nathan Gause, MD is a Co-Chair of the JRGOS Foundations in Orthopaedic Surgery (JFOS) Symposium recently held at the University of Missouri-Kansas City (UMKC) in May 2025 which hosted Newly Matched Interns, Residents, and Attendings.
L. Nathan Gause, MD is an Assistant Professor at the Department of Orthopaedics at the University of Missouri-Kansas City (UMKC), the Vice Chair, Clinical Operations Chief, Foot and Ankle Service Department of Orthopaedic Surgery Chair, Council for Inclusive Excellence UMKC School of Medicine, Kansas City Medical Director, and Health Equity Physician Informaticist University Health KC.
This case report presents the management of a 20-year-old male who sustained a Weber Type C pronation-external rotation ankle fracture after falling from an 8-foot ladder at work.
Preoperative radiographs of the right ankle demonstrating medial clear space and syndesmotic widening as well as a diaphyseal fibular fracture.
The initial surgical plan included open reduction and internal fixation (ORIF) of the fibula and syndesmosis, along with repair of the deltoid ligament. However, during surgery, after exposing the deltoid ligament and laterally subluxating the tibiotalar joint to visualize the plafond and talar dome, the posterior tibial tendon (PTT) appeared flaccid. Upon extending the incision proximally, the surgical team discovered a complete myotendinous rupture of the PTT.
Subsequently, the fibula was stabilized using lateral fixation with a suture-button suspensory device. The deltoid ligament was repaired with suture anchors, and the PTT was reconstructed using #2 nonabsorbable suture.
Postoperative radiographs demonstrating suture anchor repair of the deltoid ligament, suture button fixation of the syndesmosis, and internal fixation of fibula fracture.
A literature review identified 32 previously reported cases of traumatic PTT rupture, all linked to high-energy mechanisms, most commonly associated with pronation-external rotation or pronation-adduction Lauge-Hansen injury patterns. The PTT plays a crucial role in supporting the medial longitudinal arch, and its dysfunction can lead to progressive pes planus and ambulatory pain.
The authors emphasize the difficulty of diagnosing PTT injuries preoperatively and recommend maintaining a high index of suspicion in high-energy, pronation-type injuries. They suggest that preoperative MRI may aid in identifying such injuries before surgery.
